Intraventricular Extension of Supratentorial Intracerebral Hemorrhage: The Modified Graeb Scale Improves Outcome Prediction in Lund Stroke Register

The role of high-sensitivity C-reactive protein serum levels in the prognosis for patients with stroke: a meta-analysis

Background

The impact of high-sensitivity C-reactive protein (hs-CRP) as a biomarker of inflammation on the prognosis of stroke patients remains controversial, this study was conducted to evaluate the prognostic value of hs-CRP levels for patients with stroke.

Methods

PubMed, Web of Science, Embase, and Cochrane Library databases were searched from inception to October 28, 2022. Outcome measures were all-cause mortality, recurrent stroke, and poor prognosis. The relationship between the highest versus lowest levels of hs-CRP or per unit increment and outcomes as measured by risk ratio (RR) and corresponding 95% confidence intervals (CI).

Results

A total of 39 articles were eligible for meta-analysis. High hs-CRP levels at admission were associated with mortality among patients with acute ischemic stroke (AIS) [RR = 3.84, 95% CI (2.41 ~ 6.111); p < 0.001], risk of recurrent stroke [RR = 1.88, 95%CI (1.41 ~ 2.52); p < 0.001], and poor prognosis [RR = 1.77, 95% CI (1.59 ~ 1.97); p < 0.001]. The risk ratios for the association of per unit increase in hs-CRP levels with mortality, risk of recurrent stroke, and poor prognosis were as follows, respectively: 1.42 [95% CI (1.19-1.69); p < 0.001], 1.03 [95% CI (1.01-1.04); p = 0.003], and 1.27 [95% CI (1.10-1.47); p = 0.001]. For hemorrhagic stroke (HS), the risk ratios (RR) for the highest versus the lowest (reference) category of hsCRP or per unit increment to all-cause mortality were 4.36 [95% CI (1.38-13.73); p = 0.012] and 1.03 [95% CI (0.98-1.08); p = 0.238].

Conclusion

Hs-CRP levels are strongly associated with mortality, risk of stroke recurrence and poor prognosis in stroke patients. Therefore, hs-CRP levels may contribute to the prognosis prediction of these patients.

Combining modified Graeb score and intracerebral hemorrhage score to predict poor outcome in patients with spontaneous intracerebral hemorrhage undergoing surgical treatment

Objective

Spontaneous intracerebral hemorrhage (sICH) is a frequently encountered neurosurgical disease. The purpose of this study was to evaluate the relationship between modified Graeb Score (mGS) at admission and clinical outcomes of sICH and to investigate whether the combination of ICH score could improve the accuracy of outcome prediction.

Methods

We retrospectively reviewed the medical records of 511 patients who underwent surgery for sICH between January 2017 and June 2021. Patient outcome was evaluated by the Glasgow Outcome Scale (GOS) score at 3 months following sICH, where a GOS score of 1–3 was defined as a poor prognosis. Univariate and multivariate logistic regression analyses were conducted to determine risk factors for unfavorable clinical outcomes. Receiver operating characteristic (ROC) curve analysis was performed to detect the optimal cutoff value of mGS for predicting clinical outcomes. An ICH score combining mGS was created, and the performance of the ICH score combining mGS was assessed for discriminative ability.

Results

Multivariate analysis demonstrated that a higher mGS score was an independent predictor for poor prognosis (odds ratio [OR] 1.207, 95% confidence interval [CI], 1.130–1.290, p < 0.001). In ROC analysis, an optimal cutoff value of mGS to predict the clinical outcome at 3 months after sICH was 11 (p < 0.001). An increasing ICH-mGS score was associated with increased poor functional outcome. Combining ICH score with mGS resulted in an area under the curve (AUC) of 0.790, p < 0.001.

Conclusion

mGS was an independent risk factor for poor outcome and it had an additive predictive value for outcome in patients with sICH. Compared with the ICH score and mGS alone, the ICH score combined with mGS revealed a significantly higher discriminative ability for predicting postoperative outcome.

Sustained Low-Efficiency Dialysis is Associated with Worsening Cerebral Edema and Outcomes in Intracerebral Hemorrhage

BACKGROUND/OBJECTIVES

We postulated that renal replacement therapy (RRT) in ICH patients with advanced chronic kidney disease (CKD) is associated with increased frequency and size of perihematomal edema (PHE) expansion and worse patient outcomes.

METHODS

The Get With the Guidelines-Stroke Registry was queried for all patients admitted with ICH (N = 1089). Secondary causes, brainstem ICH, and initial HV < 7 cc were excluded. We identified patients with advanced CKD with and without RRT following admission for ICH. ABC/2 formula was used to measure hematoma volume (HV) and PHE. Patient outcomes were 30-day mortality, 90-day modified Rankin Scale score, and discharge disposition. We used propensity scores and optimal matching to adjust for multiple covariates.

RESULTS

At 48 h post-ICH, PHE expansion was a significant predictor of poor patient outcomes in our cohort. Patients with CKD who received sustained low-efficacy dialysis (SLED) treatment had larger 48 h PHE growth compared to both untreated CKD group (average treatment effect (ATE), 11.5; 95% CI, 4.9-18.1; p < 0.01) and all untreated patients (ATE, 7.43; 95% CI, 4.7-10.2; p < 0.01). Moreover, patients with RRT had significantly worse functional and mortality outcomes.

CONCLUSIONS

SLED treatment in ICH patients with CKD was associated with significant increase in rate and frequency of PHE expansion. Absolute increase in PHE during 48-h post-ICH was associated with increased mortality and worse functional outcomes. Further prospective and multicenter evaluation is needed to differentiate the effects of RRT on hematoma dynamics and patient outcomes from those attributed to CKD.

The slice score: A novel scale measuring intraventricular hemorrhage severity and predicting poor outcome following intracerebral hemorrhage

OBJECTIVES

To quantify extent of intraventricular hemorrhage (IVH) following intracerebral hemorrhage (ICH) with a novel, simple IVH severity score, and to explore and compare its performance in predicting worse outcomes.

PATIENTS AND METHODS

A new scoring system for IVH severity was proposed and termed Slice score. The Slice score features non-septum pellucidum section, internal capsule section, third ventricle occipital horn section, three standardized scans for scoring the lateral ventricles. 652 scans from 326 subjects were retrospectively analyzed. The correlations between measured IVH volume and Slice score, original Graeb, LeRoux, and IVH score (IVHS) were compared. The association between these scores and clinical outcomes were evaluated using logistic regression. We then identified clinical thresholds of Slice score by balancing the probability of prediction and accuracy. Primary outcome was defined as 90-day poor outcome (modified Rankin Scale score ≥ 4) and secondary outcome was 90-day mortality.

RESULTS

Of 326 ICH patients, 122 (37.4%) had poor outcome and 59 (18.1%) died at 3 months. The Slice score showed the highest correlation with measured IVH volume (R = 0.73, R² = 0.54, p < 0.001). The observed area under the curve were similar among the Slice, original Graeb, LeRoux score, and IVH score for poor outcome (0.633, 0.633, 0.632, 0.634, respectively), and for mortality (0.660, 0.660, 0.660, 0.656, respectively). All IVH scales were independently associated with 90-day poor outcome and mortality with close odds ratio in adjusted models (all odds ratio > 1.07, all p < 0.05). Multivariable Analyses of categorized Slice score revealed optimal thresholds of 6 and 12 for primary and secondary outcomes (odds ratio 4.20, 95% confidence interval 1.82-10.02, p = 0.001; odds ratio 5.41, 95% confidence interval 1.66-17.43, p = 0.005, respectively).

CONCLUSIONS

The Slice score correlated highly with the IVH volume, was a reliable volumetric scale for measuring IVH severity, and could be an easy-to-use tool for predicting 90-day poor outcome and mortality in ICH.

Original and Modified Graeb Score Correlation With Intraventricular Hemorrhage and Clinical Outcome Prediction in Hyperacute Intracranial Hemorrhage

Background and Purpose- The Graeb score is a visual rating scale of intraventricular hemorrhage (IVH) on noncontrast head CT. Little data exist in the hyperacute (<6 hour) period for reliability and predictive value of the modified Graeb Score (mGS) or the original Graeb Score (oGS) for clinical outcomes or their correlation with quantitative IVH volumes. Methods- A retrospective analysis of multicenter prospective intracranial hemorrhage study was performed. oGS and mGS inter-observer agreement and IVH volume correlation on the baseline noncontrast head CT were calculated by intraclass correlation coefficient and Pearson coefficient respectively. Predictors of poor outcome (modified Rankin Scale scores ≥4) at 3 months were identified using a backward stepwise selection multivariable analysis. oGS and mGS performance for modified Rankin Scale scores ≥4 was determined by receiver operating characteristic analysis. Results- One hundred forty-one patients (65±12 years) with median (interquartile range) time to CT of 82.5 (70.3-157.5) minutes were included. IVH was observed in 43 (30%) patients. Inter-observer agreement was excellent for both oGS (intraclass correlation coefficient, 0.90 [95% CI, 0.80-0.95]) and mGS (intraclass correlation coefficient, 0.97 [95% CI, 0.84-0.99]). mGS (R=0.79; P<0.01) correlated better than oGS (R=0.71; P<0.01) with IVH volumes (P=0.02). Models of thresholded oGS and mGS were not different from a model of planimetric baseline intracranial hemorrhage and IVH volume for poor outcome prediction. Area under the curves were 0.70, 0.73, and 0.72, respectively. Conclusions- Excellent correlation for oGS and mGS with IVH volume was seen. Thresholded oGS and mGS are reasonable surrogates for planimetric IVH volume for hyperacute intracranial hemorrhage studies.

Risk of Long-Term Mortality for Complex Chronic Patients with Intracerebral Hemorrhage: A Population-Based e-Cohort Observational Study

INTRODUCTION

Over recent years there has been growing evidence of increased risk of mortality associated with hemorrhagic stroke among older patients. The main objective of this study is to propose and validate a prognostic life table for complex chronic patients after an intracerebral hemorrhage (ICH) episode in primary care settings.

METHODS

This was a multicenter and retrospective study (April 1, 2006-December 31, 2016) of a cohort from the general population presenting an episode of ICH from which a predictive model of mortality was obtained using a Cox proportional hazards regression model. In addition, Kaplan-Meier survival curves, the log-rank test, receiver operating characteristic (ROC) curves, and area under the ROC curve (AUC) were used to evaluate the ability to stratify patients according to vital prognosis. We proceeded to external validation of the model through prospective monitoring (January 1, 2013-December 31, 2017) of the population of complex chronic patients with an episode of ICH.

RESULTS

A total of 3594 people aged ≥ 65 years were identified as complex chronic patients (women 55.9%; mean age, 86.1 ± 8.4 years) of whom 161 suffered hemorrhagic stroke during the study period (January 1, 2013-December 31, 2017). The primary outcome was death from any cause within 5 years of follow-up after an ICH episode. The independent prognostic factors of mortality were age > 80 years (HR 1.048, 95% CI 1.021-1.076, p < 0.001) and HAS-BLED score (HR 1.369, 95% CI 1.057-1.774, p = 0.017). Compared to the general population, the incidence density/1000 person per year (15 vs 0.22) was significantly higher with a significantly lower annual lethality rate (17% vs 49.2%); and both the prognostic factors and the risk of stratified mortality showed different epidemiological patterns. The internal validation of the model was optimal (log-rank < 0.0001) in the general population, but its external validation was not significant in the complex chronic patient population (log-rank p = 0.104).

CONCLUSIONS

The ICH-AP is a clinical scale that can improve the prognostic prediction of mortality in primary care after an episode of ICH in the general population, but it was not significant in its external validation in a population of complex chronic patients.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03247049.

Minimally Invasive Evacuation of Severe Intraventricular Hemorrhage Using the BrainPath Endoport-Assisted Microsurgical System

OBJECTIVE

We present the application of the BrainPath endoport-assisted microsurgical device (EAMD) as a treatment modality for patients with severe intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial intracerebral hemorrhage (sICH).

METHODS

Patients with severe secondary IVH (defined as Graeb score [GS] >6) who presented to Saint Louis University Hospital, St. Louis, Missouri, United States, from 2017 to 2019 were treated with the minimally invasive approach for IVH evacuation using the atraumatic BrainPath aspiration system.

RESULTS

Three patients (2 men and 1 woman) with a mean age of 54 years were included in this study. The mean preoperative GS was 10.0 with a modified GS of 23.3. The mean postoperative GS was 4.0 (P = 0.001) with a modified GS of 10.67 (P = 0.001). There were no complications related to the surgery itself in any of the reported cases.

CONCLUSIONS

BrainPath EAMD evacuation of severe IVH secondary to sICH appears to be a safe and effective treatment modality that significantly increases the extent of IVH clearance, which could also lead to improved long-term patient outcomes.

Prognostic impact of leukocytosis in intracerebral hemorrhage: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Intracerebral hemorrhage (ICH) is correlated with high rate of death and poor outcome. Leukocytes participate in secondary brain injury in ICH. It is still not clear that whether leukocytosis can predict outcome in ICH. This study was performed to summarize that current evidences about the association between baseline leukocytosis and outcome in ICH patients in a systematic review and meta-analysis.

METHODS

Published studies were searched in 5 databases. Original studies about association between baseline leukocytosis and outcome in ICH were included. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were achieved to evaluate the association between leukocytosis and prognosis.

RESULTS

A total of 19 eligible studies with 6417 patients were analyzed in this study. Meta-analysis showed baseline leukocyte count increase was significantly associated with worse overall (OR = 1.13, 95% CI 1.05-1.21, P = .001), short-term (OR = 1.20, 95% CI 1.05-1.38, P = .009), and long-term functional outcome (OR = 1.12, 95% CI 1.04-1.20, P = .004). Baseline leukocytosis defined by cut-off values had significant association with worse overall functional outcome (OR = 1.95, 95% CI 1.01-3.76, P = .046). Baseline leukocyte count increase was significantly associated with higher overall (OR = 1.10, 95% CI 1.02-1.18, P = .011) and long-term mortality (OR = 1.12, 95% CI 1.03-1.22, P = .007). Baseline leukocytosis defined by cut-off values was significantly associated with higher overall (OR = 1.67, 95% CI 1.23-2.27, P = .001) and short-term mortality (OR = 1.74, 95% CI 1.12-2.70, P = .014).

CONCLUSION

Baseline leukocytosis could be helpful in predicting prognosis in ICH patients. However, its prognostic value should be verified by further studies.

Intraventricular Hemorrhage Severity as a Predictor of Outcome in Intracerebral Hemorrhage

Background/Objective: Intraventricular hemorrhage (IVH) extension after spontaneous supratentorial intracerebral hemorrhage (sICH) is an independent predictor of worse outcome. However, there is a paucity of data looking at the degree of IVH severity and its impact on outcome. This study addresses the contribution of IVH severity to outcome at time of hospital discharge after sICH.

Methods: Two hundred and ten patients were included in the study. Baseline demographic and radiologic characteristics were abstracted. First available CT scans were reviewed for hematoma volume and location, IVH extension and presence of hydrocephalus (HCP). IVH severity was calculated using Graeb scale. Multivariate logistic regression models were developed to investigate the association of IVH severity with poor outcomes at hospital discharge, defined as modified Rankin scale score (mRS) >3.

Results: Fifty-three percent of patients had IVH extension while 18% had surgical procedures done. Poor outcome (mRS >3) was seen for 56% of patients. Median IVH extension severity on the Graeb scale was two. Presence of IVH was associated with poor outcome in univariate and multivariate analysis (p < 0.005). Compared to patients with no IVH, IVH severity influenced outcome only when Graeb scores were ≥5 (OR = 1.3, 95% CI 0.49–3.23, p = 0.63, and OR = 2.9, 95% CI, 1.1–7.6, p = 0.03 for Graeb <5 and ≥5, respectively.

Conclusions: Higher IVH severity (defined as Graeb score ≥5) is associated with worse outcome at time of hospital discharge, while lower IVH severity (Graeb scores 1–4) has similar outcomes to patients without IVH. IVH severity should be used in favor of IVH presence for prognostication purposes.

Prediction of Long-Term Outcome After Intracerebral Hemorrhage Surgery

BACKGROUND

Surgery for spontaneous primary intracerebral hemorrhage (ICH) remains controversial. Previous surgical trials have primarily focused on short-term mortality while studies on long-term functional outcome are rare. We therefore conducted this retrospective study of long-term outcome on all ICH patients who underwent craniotomy at a single neurosurgical center during a 10-year period.

METHODS

We included all patients >15 years of age who underwent evacuation of spontaneous ICH at Skåne University Hospital between 2003 and 2012. Case fatality at 30 days, 1 year, and long-term follow-up (up to 10 years) were analyzed in relation to potential predictors of outcome. Long-term functional outcome was assessed in 2013 by telephone interview using the modified Rankin Scale (mRS).

RESULTS

Of 229 operated patients, overall case fatality was 20% at 30 days and 31% at 1 year. For patients with supratentorial ICH, the case fatality was 16% at 30 days and 27% at 1 year, and 29% at 30 days and 41% at 1 year for patients with cerebellar ICH. The most consistent independent predictors of mortality were preictal heart disease and level of consciousness on admission. Of 185 patients with long-term functional outcome available (median follow-up 6.14 years), 44 of them (24%) had a good outcome (mRS score 0-3) and 141 (76%) were severely disabled or dead (mRS score 4-6).

CONCLUSIONS

The case fatality in our study was comparatively low, but most survivors lived dependently several years after surgery. Heart disease and level of consciousness were the most consistent predictors of mortality.

The Effect of Transtemperal Approach and Placement of Intracranial Pressure Sensor Into Temporal Horn of Lateral Ventricle in Management of Spontaneous Supratentorial Intracerebral Hemorrhage Broken Into Ventricles

To investigate the effect of transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle in management of spontaneous supratentorial intracerebral hemorrhage broken into ventricles, a total of 37 patients with spontaneous supratentorial intracerebral hemorrhage broken into ventricles treated by operation from January 2016 to December 20l6 were analyzed retrospectively, of which 25 patients in simple transtemporal approach group and 12 patients in transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle group. All patients were followed up for 8 months to 1.5 years. Two groups were estimated by mortality, clearance rate of hematoma, removal rate of bone flap, good prognosis rate of ADL and incidence of hydrocephalus. The good prognosis rate of ADL and the incidence of hydrocephalus are only statistically significant between the two groups (P < 0.05). According to the result, the transtemperal approach and placement of intracranial pressure sensor into temporal horn of lateral ventricle in management of spontaneous supratentorial intracerebral hemorrhage broken into ventricles is a safe, effective, and less complication of treatment measure.

Intracerebral Hemorrhage with Intraventricular Extension—Getting the Prognosis Right Early

Background

Early accurate outcome prognostication for patients with intracerebral hemorrhage (ICH) and accompanying intraventricular hemorrhage (IVH) is often challenging (1). Acute hydrocephalus often contributes to a poor clinical exam (2) and can portend significant morbidity and mortality (3). Accordingly, the inpatient neurologist may feel inclined to recommend limitations of care for an ICH patient admitted with a large IVH burden and poor exam.

Case presentation

We present a patient with significant IVH and minimal ICH who deteriorated rapidly to coma after presentation. Despite this exam, an initially non-functioning diversion of cerebrospinal fluid (CSF) and temporary halt of further attempts of CSF diversion in the setting of an early “do not resuscitate order,” our patient gradually improved and, with supportive ICU care and rehabilitation, was able to communicate and ambulate with assistance at 12 weeks.

Conclusion

Patients with ICH with IVH do have the capacity to improve dramatically even with relatively conservative management. Unless previous limitations of care exist, we recommend that early judgments of prognosis for patients with ICH and/or IVH should be delayed for at least 72 h until the patient’s clinical trajectory over time is better understood.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial

BACKGROUND

Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

METHODS

In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134.

FINDINGS

Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar.

INTERPRETATION

In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status.

FUNDING

National Institute of Neurological Disorders and Stroke.

Applicability of Clinical Trials in an Unselected Cohort of Patients With Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Patient selection in clinical trials on intracerebral hemorrhage (ICH) affects overall applicability of results. We estimated eligibility for completed, ongoing, and planned clinical trials in an unselected cohort of patients with ICH.

METHODS

Large clinical ICH trials were identified using trial registration databases. Each trial's inclusion criteria were applied to a consecutive group of patients with ICH from the prospective hospital-based Lund Stroke Register. Survival status was obtained from the National Census Office and 90-day poor functional outcome (modified Rankin Scale ≥4) from the Swedish Stroke Register or medical files.

RESULTS

Among 253 patients with ICH, estimated eligibility proportions ranged between 2% and 36% for the 11 identified clinical trials. Patients not eligible for any trial (n=96) had more intraventricular hemorrhage, lower baseline level of consciousness, higher rates of cerebellar ICH, and lower rates of lobar ICH (P≤0.001). Thirty-day case fatality for noneligible patients was 54% versus 18% among patients eligible in ≥1 trial (95% confidence interval, 44%-64% versus 13%-25%; P<0.001). Noneligible ICH patients more frequently had poor functional outcome (75% versus 48%; 95% confidence interval, 65%-83% versus 40%-56%; P<0.001).

CONCLUSIONS

There is large variation in proportions of patients with ICH eligible for inclusion in clinical trials and over a third of patients with ICH are not eligible for any trial.